Prepare for the Worst

De-escalation Training Arms Hospitalists With Measures to Calm Agitated Patients

Karen Appold


The Hospitalist. 2015;19(3):30-31. 

In This Article

Appropriate Responses

By the nature of their work, hospitalists regularly come into contact with agitated patients. "Knowing how to safely help a patient calm down will result in better outcomes for the patient, the physicians, and everyone nearby," Dr. Zeller says.

"Hospitalists should focus on what they can control," says Judith Schubert, president of Crisis Prevention Institute (CPI), a Milwaukee, Wis.-based company that offers de-escalation training in 400 cities annually. This includes physicians' own behavior/demeanor, responsiveness, environmental factors, communication protocols, and a continuous assessment of risk and an understanding of how to balance duty of care with responsibilities to maintain safety.

Hospitalists should be aware of behaviors that could lead to volatility.

"Challenging or oppositional questions and emotional release or intimidating comments often mark the beginning stages of loss of rationality. These are behaviors that warrant specific, directive intervention aimed at stimulating a rational response and diffusing tension," Schubert says. "Before it even gets to that point, empathy, demonstrated with the patient and family members, can reduce contagion of emotional displays that are likely rooted in fear and anxiety."

Agitation usually doesn't arise out of the blue.

"It is typically seen over a spectrum of behaviors, from merely restless and irritable up to sarcastic and demeaning, pacing, unable to sit still, all the way up to screaming, combative, and violent to persons and property," Dr. Zeller says. "It is best to intervene in the earlier stages and help a person to calm before a situation gets out of hand."

Thus, hospitalists should be wary of people who are increasingly hostile and energetic and should seek help or work to de-escalate promptly.

Although you may suspect that patients with mental illnesses are more prone to volatility, Dr. Zeller says that isn't necessarily the case. The most common psychiatric illnesses that can lead to agitation are schizophrenia and bipolar mania. In addition, being intoxicated—especially with alcohol and stimulants—can predispose someone to agitation. Many other medical conditions can cause someone to become agitated, such as confusion, a postictal state, hypoglycemia, or a head injury.